Authorization for Disclosure of Protected Health Information (PHI)

(Patient Permission to Release Information in the Medical Record)

Please correct the errors described below.

Release Information From:

Release Information To:

• Dr.Otha Myles & Associates, LLC has my permission to use or give out certain information in my medical record. The information the they may give out is check below.

• I also understand the PHI (protected health information) may include information protected under Federal and State Law (such as information about alcohol, drug abuse, mental health, HIV, and/or AIDS treatment.

Expiration of the Authorization: I understand that I may revoke this authorization at any time by sending a written notice to Dr. Myles & Associates, LLC at the address noted below. I understand that the revocation will not apply to any PHI that has already been released in association with this authorization.

I have read and understood this Authorization and my questions have been answered. I certify that I am the Patient listed above or a person with permission to act on Patient's behalf. I will not hold Dr. Myles & Associates, LLC its officers, trustees, employees, agents, or contractors responsible for anything that may happen from the use or release of my PHI.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.